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Rising PSA after RT - what next?

User
Posted 27 Jul 2014 at 01:11

Had my RT in 2008 as shown in my profile but after my PSA nadir which was .05 it has subsequently risen on each of my 6 monthly checks in recent years. It now stands at 1.45 having risen by .23 in the last six months. At this sort of rate of increase it will be biochemical failure in about 12 or so months time, ie 2+my nadir of .05 making 2.05.

In previous consultations with the Marsden, when I asked about the level at which intervention would be made I was not given a definitive PSA level though on one occasion 4 was mentioned and an even higher figure another time before this would be considered. However, when I had my telephone consultation with a junior doctor on 24th July 2014, the subject of salvage treatment came up and this doctor asked what I felt about having surgery. I said that when I was diagnosed back in 2007 the surgeon said he was doubtful about being able to remove all my cancer and he suggested I have RT instead. It would now be even more difficult to remove the prostate after RT assuming that a surgeon would be prepared to do this anyway. It might achieve nothing more but leave me incontinent. I said that in the circumstances I would prefer an alternative treatment if there was still cancer in my Prostate maybe HIFU which she mentioned as a possibility or cryotherapy etc., If the cancer had gone elsewhere, perhaps HT would treat more systemically. It was necessary to ascertain where the PSA producing cells were. A choline PET scan was mentioned as a possibility and the doctor said she would consult her senior doctor on this. I will see whether this is offered and if so at what point. If it is not offered, I will check with a contact I have in the University Hospital Heidelberg where I had my RT whether they think it would be helpful to have the Gallium 68 - PSMA PET Scan now or at some point as this seems to provide clearer results than even the Choline PET Scan. http://link.springer.com/article/10.1007%2Fs00259-013-2525-5

So it's wait and see what's next.

Barry
User
Posted 27 Jul 2014 at 12:45
Hi Barry

As you know I am a advocate of PET/CT Scans, as I believe there is benefit in a more targeted treatment when you know where the spread is. Have you heard of the term Dose Painting, this is where they apply more radiation to the affected area and a lower dose to the surrounding area, this I believe is being trialled at the Royal Marsden, so might be worth asking, as I think this may need a PET/CT scan to plan the treatment so it hits the affected area more precisely.

Good Luck

Roy

User
Posted 29 Jul 2014 at 01:10
Hi Roy,

Thanks for your comments. Prepared a fairly long reply yesterday but crashed just before submitted. But essentially, I hadn't heard of 'Dose Painting' but on checking this it is being trialled at the Marsden and Clatterbridge. It seems to be another way of giving RT though and as I was told that I had received my full whack of RT - except a small amount for treating bone mets palliatively if needed - I am very doubtful whether I would qualify for it. I did ask the junior doctor at my consultation if Cyberknife was given as a salvage treatment for failed IMRT as somebody on the forum thought it might be. The doctor said she was not aware of this but said it was being trialled as a main treatment. Cyberknife is yet another way of giving RT, one of a growing number of ways. Whether one method is shown to be better overall or in particular circumstances only time will tell.

I think the way forward for me is to see what the Marsden say in their follow up letter to my GP. If they don't suggest a way forward, I will ask whether the doctors in Heidelberg think it is too early to have the 68 Gallium scan yet with my PSA history and most recent PSA level or at what point this scan might help show where the PSA was being generated so salvage treatment of one sort or another could be instigated.

Barry
User
Posted 29 Jul 2014 at 09:06
Hi Barry

Sorry I think I must have had a Senior Moment regarding the RT side of things, I think your approach is wise in respect of pinpointing the spread and then to evaluate the relevant treatments available to you. I wish you well in your quest.

Roy

User
Posted 29 Jul 2014 at 10:57
Hi Barry,

We had a little chat in Leicester and I've just read your profile. Three things strike me. 1 your junior consultant doesn't seem to be completely on the ball. 2 you are aware that neither further RT or an RP are reasonable options. 3 you last had HT nearly 7 years ago.

Perhaps however reluctantly it is time to consider HT again. If I was in your place I would get a PSA figure settled in my mind, be it 2.0, 4.0 or whatever ( some oncologists are even saying 20.0 is a good starting place )and when that figure is reached go onto HT.

Having said that I'm not in your place so can't make decisions for you.

As always though I wish you well and it was good having that chat with you in June

Take care my friend

Life is for living

Barry ( alias Barrington )

User
Posted 29 Jul 2014 at 18:31
I set my ceiling at 4 before I went back to HT, I personally wouldn't go above that figure.

Hope that helps.

Chris.

User
Posted 29 Jul 2014 at 23:49
Thank you for your thoughts friends. I was particularly pleased to hear from Barry TG who despite his own very severe problems still makes time to help others and this is very much appreciated.

Barry and Chris were both at Leicester, so will remember that I asked the guest Oncologist at that meeting at what point, after RT was shown to have failed (ie nadir + 2), further intervention should be considered. He said this was a grey area and it seems this may vary from one patient to another depending on the oncologist and the patient. However, to my simplistic way of thinking, if the the PSA is still coming only from the prostate, it would make sense to try other treatments to eradicate it there before it migrates. If the cancer is shown to have migrated already, then as Barry says, perhaps HT would be appropriate. I would have thought in this latter case it would be better to start the HT earlier rather than wait until it had taken a strong and maybe widespread hold. The question is at what point is a scan helpful to determine where the cancer cells are. With standard scans there can be difficulty in establishing this until the cancer cells become greater and give off more PSA (sometimes). But it may be that the more advanced Choline and 68 Gallium scans can determine where they are earlier and thereby enable appropriate treatment sooner.

Will keep you posted as I am sure there are others in a similar position.

I formed the same opinion as you Barry regarding my consultation with my very nice but inexperienced doctor. But to be fair she did say she would refer my case to a senior doctor. I shall have to see what is suggested but if a way forward is not offered, I will obtain the views of the doctors in Heidelberg on whether a 68 Gallium scan could be really useful at this point.

Barry
User
Posted 30 Jul 2014 at 07:25
Barry

I agree with you that if it is just coming from the prostate can other treatment specifically target that?

Regarding intervening at what level of PSA I believe the oncol at Leicester also talked about velocity, how fast is it rising. That is something I would discuss with the medical team

Bri

 
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